Web-based therapy helps prevent suicidal ideation among interns

Where: Teaching hospitals at Yale University in New Haven, Conn., and the University of Southern
California (USC) in Los Angeles.

The issue: Preventing suicidal ideation among medical interns.

Background

Resident physicians are at high risk for depression. From 1963 to 2015, the overall
prevalence of depression or depressive symptoms among residents was about 29%, according
to a meta-analysis published in the Dec. 8, 2015, Journal of the American Medical Association.

Many potential factors come together to increase risk, including that many trainees
have a history of depression and are therefore more prone to experiencing these symptoms,
according to Constance Guille, MD, MS, assistant professor at the Medical University
of South Carolina (MUSC) in Charleston and a coauthor of the study.

But training can make the situation much worse. One of Dr. Guille's prior studies,
published in 2010 by Archives of General Psychiatry, showed a dramatic increase in depressive symptoms among physician trainees during
their internship years. “I think that it's the interaction between having some
kind of predisposing traits and then also a really intense, stressful experience of
internship year,” she said.

In an effort to prevent suicidal ideation among interns, Dr. Guille tested a Web-based
cognitive behavioral therapy (CBT) intervention. Encouraging results were published
in November 2015 by JAMA Psychiatry.

How it works

The Web-based CBT program used in the study, MoodGYM, was developed by staff at the
National Institute for Mental Health Research at the Australian National University.
“Those online cognitive behavioral therapy interventions have been tested in
populations that are currently symptomatic . . . and they've shown that you can reduce
suicidal ideation with those interventions,” Dr. Guille said. “I think
what's novel about ours is that we've shown that we can actually prevent suicidal
ideation, so we're not waiting for people to develop problems; we're intervening so
that we don't have problems down the road.”

MoodGYM is free and open to the public. “That's exactly why we chose it. Anybody
that has Internet access can use this, thus increasing chances of it being disseminated
and implemented,” Dr. Guille said.

In her study, medical interns in the intervention group underwent 4 weekly MoodGYM
sessions that lasted about 30 minutes each, whereas those in the control group received
4 weekly emails with general information about depression and how to get help. To
assess suicidal ideation, researchers had the trainees complete the Patient Health
Questionnaire-9 (PHQ-9) prior to the start of their internship year and at 3-month
intervals throughout the year.

Results

The study included 199 interns from Yale and USC. Over the course of the internship
year, at least 1 instance of suicidal ideation was reported by only 12% of interns
in the intervention group versus 21.2% of those in the control group.

After researchers adjusted for factors that have been shown to increase suicidal ideation
risk (sex, pre-internship PHQ-9 scores, history of depression, neuroticism, and early
family environment), interns in the intervention group were 60% less likely than control
participants to report suicidal ideation during their internship year. The risk reduction
translated into a number needed to treat of 11. “We were hoping we would see
some effect, but we were really excited about how big the effect was,” Dr.
Guille said.

She said a surprising aspect of the study was how willing interns were to participate:
62.2% of those approached by researchers agreed to take part, potentially showing
that prevention programs pose less stigma than treatment programs.

Challenges

Despite the known increase in suicidal ideation and other mental health issues during
the internship year, prior research has shown that very few affected trainees seek
treatment. In Dr. Guille's previous research, interns pointed to lack of time, access,
and confidentiality. Some also feared that reporting mental health treatment would
affect their state medical licensure, she said. “I think that people have concerns
that if others knew that they had depression or mental health problems, they wouldn't
think as highly of them,” she said.

The Web-based preventive intervention tackled not only access and confidentiality
issues but also the complaint of time constraints. “We moved the intervention
to before people actually started internship year, when they have more time. . . .
If we are seeing every year that we are having these really high rates of suicidal
ideation and [mental health] problems, then we should try to prevent them as opposed
to wait for when people actually had them,” she said.

Next steps

Although her results have been met with enthusiasm and excitement, Dr. Guille said
she and her colleagues are trying to replicate their findings before encouraging implementation.
“So we're looking at those data right now,” Dr. Guille said. “If
it turns out that it's favorable, then we'll more than likely approach our administration
to implement at the MUSC.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.